Transition To Managed Medicaid Hits Some Bumps

Mar 20, 2014

It’s been a little more than 100 days since the state of New Hampshire dramatically re-shaped its biggest program. On December 1st, traditional Medicaid became Medicaid Managed Care, shifting administration of the health program into the hands of private companies in the hopes of saving $15 million a year.

Perhaps the biggest change to the program for recipients revolves around something called prior authorizations.

The three managed care companies, known as MCOs, now require proof that you actually need a prescription or procedure before they’ll pay for it. That is very different from how things used to run.

“As long as the primary care, the pediatrician approved it, we never had a problem,” says Denise Colby of Belmont. “We never had to deal with calling Medicaid, looking for answers…it was always smooth.”

The prior authorization process has been anything but smooth for her 5-year old son Christian.

He’s on the autism spectrum, and also suffers from EE disease, a painful condition that impacts swallowing. Christian takes a daily oral steroid that runs more than $300 a month, even for the generic.

In December, when Denise went to get a refill, the pharmacy told her the managed care company wouldn’t cover a full month’s supply.

So, she called the doctor, who then called the MCO, which re-ran the prescription through its billing system. But it still came back rejected.

There were more calls over the next few weeks. Colby kept getting a different representative, and a different answer.

“This time I demanded to speak to a case manager, a care manager, whatever their title was for somebody in charge,” says Colby.

A higher-up at the MCO did get approval for Christian’s medicine. But, not every person on Medicaid has a persistent advocate in his or her corner.

A System Of Oversight

To ensure no one is denied prescribed care, the state has a commission monitoring the transition. They’ve been holding hearings around the state.

“It is clear that some of the challenges that families are facing now are very real and very problematic for them,” says Don Shumway, who serves as Vice Chair.. “That is important for us to recognize, and really dedicate ourselves to those solutions.”

Shumway says frustrations among some medical providers are also bubbling up.  

Take Granite State Independent Living: a Concord non-profit that supports people with disabilities. A typical client may be an adult who uses a wheelchair after a spinal cord injury. Aides paid for by Medicaid visit daily to help, say, with preparing meals.

Joyce Sabolevski manages the program, and says the need for these services is probably not going to change. But every eight weeks, the MCO is asking Granite State Independent Living for new documentation before it will pay for it.

“The constant reevaluation, for example, like a two-month period to reevaluate whether or not that person’s condition is going to change…it is absurd, quite frankly,” says Sabolevksi.

The Long Game

No one expected a completely smooth conversion. Medicaid, after all, is a big, complicated system that provides health insurance for more than 100,000 residents, many with complicated needs.

But Lisabritt Solsky, Deputy Medicaid Director, says, big picture, the move has actually gone fairly well.

“I will say that the bumps are exactly what I anticipated. The volume has not been overwhelming or discouraging. That is not to say that they are not troubling, because in the midst of all of that is a patient, is a member, who has a reasonable expectation of care being rendered on a timely basis.”

She says the state is working with the MCOs to improve the prior authorization process and make sure they’re living up to the terms of the contracts.

And she says it will take much longer than a few months before anyone can judge the success or failure of managed care in New Hampshire.